Ibero-American Consensus on Communication Skills for Nursing Degree students

Abstract Objective: as a health care profession focused on caring for people, Nursing requires sound communication skills. Based on an international expert consensus, a proposal on learning outcomes in clinical communication for undergraduate Nursing education curricula in Spanish speaking countries is presented. Method: a steering committee, consisting of 5 nurses and experts in communication in health care sciences, drew up the first list of communication skills specific to the Nursing degree. Their proposal was reviewed and improved by a committee of 7 international scientific advisers. 70 experts from 14 countries were selected using a snowball sampling procedure and invited to participate in a distance modified Delphi consensus process in two survey rounds. Statistical analysis was carried out to establish the final consensus level for each item. Results: a questionnaire with 68 learning outcomes in clinical communications was submitted for panel assessment. In the first Delphi round, the panel reached a statistical consensus on all the items assessed. There was no need for a second round to reconcile positions. Conclusion: an academic proposal, approved by a high level of international consensus, is presented to guide and unify the learning outcomes on the clinical communication curriculum for undergraduate Nursing studies in Spanish speaking countries.


Introduction
The nurse-patient relationship is key to achieving the central purpose of Nursing care, that is, to help individuals and their families face the experiences of illness, suffering or disability effectively and acceptably, reducing their impact on the patient's daily life. This type of interpersonal relationship is more complex and deeper than a simple accompaniment of instrumental actions usually associated with the Nursing work (1)(2)(3) . Nursing health care outcomes strongly depend on the nature of the nurse-patient relationship (4)(5) . Research evidence indicates that a health professional's ability to explain, listen and empathise (6)(7) is related to the patient's capacity to follow through with medical recommendations, self-manage a chronic medical condition, and adopt preventive health behaviours. These communication skills (CS) can also improve the patients' perception and satisfaction with the care they have received (8) . Furthermore, communication among health care team members influences the quality of the work relationships, job satisfaction and patient safety (9) .
In recent years, the importance of CS in the education of future nurses and its inclusion in curricula has become increasingly evident (10)(11) . In this sense, to achieve effective teaching/learning of CS in undergraduate studies in the health professions, among other strategies (12) , it is of utmost importance to identify the most appropriate curricular content for this education level and each health profession. With this in mind, in the medical professional field, several international documents (13)(14)(15)(16)(17)(18)(19) have defined the contents and CS necessary to achieve efficient and ethical communication with patients. These proposals, with local nuances regarding their target audience and approach, have been useful to plan and develop training programs and appropriate evaluation strategies for health care workers in their different areas of influence. Some of these documents have an interprofessional health orientation with cross-cutting recommendations (e.g., the European consensus) (18) . Naturally, health professions share an important set of interpersonal skills. However, the practice of each particular profession involves specific aspects that encompass different types of interpersonal skills within the contexts where they are needed. For example, Nursing traditionally emphasises the importance of teamwork (20) and its responsibility for aspects directly related to care (21) . In addition, theorists emphasise therapeutic communication to be of major importance in the Nursing practice and insist on the need to re-examine the Nursing care philosophy, moving beyond current limits to develop a more compassionate and humane approach (22) . The essence of such "person-centred" care requires nurses to be willing and able to establish a special type of relationship with their patients, one that is closer and more continuous than those experienced with other health care professionals (23)(24) .
The pre-existing curricular proposals on clinical communication (13)(14)(15)(16)(17)(18)(19) were developed through expert consensus. In each case, the authors proposed a set of CS adapted to a specific framework (with its scientific evidence, cultural and professional determinants, and national or supranational legislation). In some cases (16)(17) , these proposals were based on previous theoretical models of clinical communication, which helped to select and articulate the set of communication competences appropriate to each professional context. However, none of the previous competence proposals was specifically aimed at defining the CS competences of future nurses (the undergraduate students attending Nursing schools). Proposing an international, expert-supported framework on CS for undergraduate Nursing students would be useful to help each Nursing school select its educational objectives. In fact, there appears to be a need to clarify communication curricula in Nursing degree studies (25)(26) . In Spain, for example, a recent study (27) carried out in 110 Nursing schools (95.6% of the country's total schools) explored the educational offer of Nursing communication education and the content covered in the degree curriculum. The study revealed that the teaching of these skills is both scarce and highly heterogeneous among the centres. This variance is not only present in the type or content of the skills required but also in the way and at what stage these CS are taught. In other Spanish-speaking American countries, Nursing schools are also in the process of integrating nurse-patient-family CS into their degree-level curricula. Having such a consensus would be of great use. Although there exist different proposals regarding the CS that should be acquired by Nursing professionals (28)(29)(30)(31)(32) , there are no similar statements on the teaching of CS within the Nursing degrees of these countries.
The objective of this study has therefore been to develop a consensus on CS (defined as learning outcomes

Method
This study uses a specific variant (33) of the modified Delphi method (34) , designed to reach group consensus in a maximum of two rounds of a written survey with

Selection of the panellists
Subsequently, panellist candidates were selected through the snowball sample technique (39) . Recruitment started from the network of professional contacts of the local SC and the international Scientific Committee, as well as other potential experts identified during the literature search, according to the inclusion criteria proposed. Based on these first elements, a cascade selection process was Rev. Latino-Am. Enfermagem 2022;30:e3523. triggered, with no limitations throughout Latin America.
All professionals who received more than one nomination for expert recognition by their peers were invited to participate.
To assemble an international panel of Nursing experts (40) with diverse and complementary profiles, during the nomination process, candidates were sought with one or more of the following eligibility criteria: recognised leadership in clinical communication; experience as an educator in a Nursing school; position of institutional responsibility (educational, care, scientific or associative); wide range of health care experience (public/ private, rural/urban). The procedure for acceptance of candidates was supervised by the Scientific Committee.

The survey, evaluation of the items by the panel and consensus criteria
The variant of the Delphi method used in the study (30) makes it possible to offer, as required for each item under analysis, up to two consecutive rounds of an electronic written survey to approximate the experts' positions and reach a consensus. To express their opinion on each item under discussion, the panellists used a 9-point Likert ordinal scale, according to the format developed at the UCLA-Rand Corporation for the method of assessing the appropriate use of health care technology (41) . The response categories on this scale were grouped into three regions (1-3 = "disagree"; 4-6 = "neither agree nor disagree"; and 7-9 = "agree"). The questionnaire offered the possibility for the participants to include free comments. Non-scored items were treated as lost cases for statistical purposes.
To analyse the group opinion and the type of consensus reached, the position of the median of the group scores and the level of agreement reached by the respondents were used according to the following criteria (41) : an item was considered consensual when there was opinion "concordance" in the panel; that is, when the experts who scored outside the region of three points containing the median ( [1][2][3], [4][5][6], [7][8][9]) were less than one-third of the respondents. In addition, the value of the median score determined the group consensus reached as "majority" disagreement with the item if the median was ≤ 3, or "majority" agreement with the item if the median was ≥ 7.

A.2.1. Establish and maintain a therapeutic relationship (Connect) (The student establishes and maintains a therapeutic relationship through a patient-centred approach)
Establish a nurse-patient relationship in which the patient feels comfortable and listened to regarding his/ her needs. 8.69 9 1 0 Perceive the patient's non-verbal language (mimic, kinaesthetic, proxemic, and tactile) and respond appropriately to the context. 8 Items with cases in region (4-6) were considered "dubious".
Panel criteria "discordance" was considered when the scores of one-third or more of the panellists were in region (1)(2)(3) and of another one-third or more in region (7)(8)(9).
After the first survey round, the experts received a

Results
Of the 89 experts who agreed to participate and served on the panel of experts, 70 completed the study.
The national origins of the panellists were Spain (38), El Salvador (2), Nicaragua (1), Costa Rica (2)  Share the range of possible consequences of a decision with the patient. 8.14 9 1 9.46 Offer the patient the option of involving third parties (colleagues, relatives) in the decision-making process.   was considered unnecessary to carry out a second survey round, given that there were no outstanding issues to be clarified or resolved after the first iteration ( Table 1).
The free comments and/or suggestions made by the panellists after the first round were analysed by pairs formed among the researchers, none of which were cause for the modification of the initial proposal Address the cultural and social diversity of the patient and family by applying specific strategies and skills that each may require. 8.45 9 1 4.05

F.1.4. Health promotion and behavioural change.
Identify the patient's accessibility to adopt healthy behaviours. 8  Overall, and related to the different thematic sections of the survey, the items belonging to the "nurse-patient Under this criterion, a group of 17 skills were selected, which reached the highest degree of panel endorsement (whose mean score was placed in the upper quartile of the distribution of averages, that is, with a mean score higher than the 75 percentile value = 8.31). These learning outcomes can be considered a priority for the experts consulted, composing a "skills core" of special interest (Table 2).

Discussion
T h e S p a n i s h -A m e r i c a n C o n s e n s u s o n It expands and reinforces some of the proposals that have been made on communicative competences for the Nursing profession within the framework of the profession's general competences (10,(28)(29)(30)(31)(32) . At the end of this process, there were 70 experts from Spain and different Ibero-American countries who developed this basic communication curriculum intending to serve as a guide to help establish the communicative learning outcomes that Nursing training in higher education may provide.
The size of this panel is larger than that used in another consensus. When, as in our case, the hypothetical population of experts available to be recruited is large and international in scope, the ideal size of the group surveyed should be considered.
Although a formal sample size calculation has never been considered necessary, in our case it seems reasonable to oversize the panel to make it more representative.
Moreover, experimental evidence has shown the direct relationship between the size of the expert panel and the precision of the group estimate obtained (the expert forecast error tends to decrease exponentially as the panel size increases) (33) .
Looking at its content and methodology, this consensus is aligned with the main statements on the teaching of CS within other health professions (13)(14)(15)(16)(17)(18)(19) . It the teaching of the degree proves to be difficult (26,42) .
In many cases, this leads to lack of training in some of them, which is also true for those of a communicational nature (43)(44)(45)(46)(47) . has been made to offer these outcomes as observable behaviours. With this in mind, they have been written as "Learning Outcomes" (LOs) and following the taxonomies of Bloom's educational objectives (38) . We therefore try to avoid debate that identifies them as "competences", Pérez AM, Gómez del Pulgar M, Ruiz R, Crespo A, García de Leonardo C, Caballero F. as this often leads to greater difficulties when setting out the LOs for teaching in a practical manner (48) . Most of these LOs are based more on behaviour and attitude than on cognitive activity. Although it might well involve several practical challenges for some institutions, incorporating them into a Nursing curriculum will also prove useful as a guide for setting out teaching and evaluation methodologies. It seems logical that, because of the nature of these LOs, for a student to incorporate and apply them, the educational institution must prioritise experiential teaching methods (15,(49)(50) .
Such methods must contemplate repeated exposure to a variety of clinical situations in which students can be observed, receive structured feedback, have enough time to reflect on what has been learned and then practise under simulated conditions. As a general rule, their teaching will require organising not in isolated courses, but throughout the curriculum and be taught by adequately trained teachers (15,(51)(52) .
All of the above represents added value to this LO proposal, one that may be of great use to many Nursing schools in the design and modification of their programs more efficiently and effectively (27) . However, it is important to bear in mind that many of these objectives require the student to understand subtle aspects of the hidden curriculum and develop intuitive thinking (53) .
This can only be accomplished slowly and with frequent and reflective practice (53)(54) . Nursing students are young, mostly inexperienced, and often have difficulty incorporating these types of skills (44,55) . This learning is by no means easy and, therefore, some adaptation and customization of the experiential educational strategies will always be required throughout their undergraduate program (26,(44)(45) .

Limitations
Both the phases that are before the Delphi process and the survey process are subjected to various types Consensus methods in general have been criticised for their limited scientific nature (57)(58) . However, the Delphi method has been widely studied and used in the health sciences, particularly in Nursing (59) .
It has been questioned whether reaching consensus is a scientific method or simply a way of structuring group allows for the identification of a potential expert through an active search through networks of potential experts and a consensus involving multiple recommendations by their peers. This was considered a more comprehensive way of carrying out the selection procedure than when done by direct selection of experts (60) . Therefore, a biased selection (based on the knowledge and convenience of the initial committee members) would have been mitigated (61) .
The above arguments make it reasonable to accept  (62) . The criterion used to mark consensus has been statistical and, although accepted, is nevertheless a discretionary criterion. Finally, another important aspect that supports the decision to employ a consensus method is that the resulting statement should be adopted and used by as many institutions, boards and organisations as possible.
To achieve this goal, it is important to involve stakeholders in the development of the consensus statement and not in the implementation process alone (63) . Due to the risks involved in unstructured debates, we believe it difficult to imagine a better way to standardise and ensure the process and its ensuing results.
Bearing all this in mind, the consensus method employed may be considered as one of the main strengths of this proposal, as it reflects the communicative requirements of a Nursing practice that can be taught to students. Finally, it can be observed that, although the experts came from countries that share the same language, there exist notable socio-cultural and economic differences between some of them. Even so, a possible biased preliminary choice of items by the Scientific Committee by the predominant cultural subgroup within the main group cannot be ruled out.

Conclusion
The